Adam Helms, MD

• Chief Medical Resident, Department of Internal Medicine, University of
• Virginia, Charlottesville, VA, USA

Pyloric antrum Cardiac part Area of stomach that communicates with esophagus superiorly n 4 medications for gout buy generic reminyl 4mg on line. Pyloric canal (contains the pyloric smooth muscle Fundus Superior part just under left dome of diaphragm sphincter that releases measured amounts of chyme into the duodenum during digestion) Body Main part between fundus and pyloric antrum Pyloric part Portion that is divided into proximal antrum and n 5 symptoms neuropathy buy 8 mg reminyl visa. Enteroendocrine cells (gastric hormones and regulatory peptides) the stomach is fexible and can assume a variety of confgura tions during digestion symptoms 6 days dpo buy reminyl amex, depending upon the contractions of its smooth muscle walls and how full and distended it is treatment west nile virus order genuine reminyl. Despite Clinical Note: this fexibility symptoms ibs cheap 4 mg reminyl amex, it still is tethered superiorly to the esophagus and Hiatal hernia is a herniation of the stomach through the distally to the frst portion of the duodenum symptoms 2016 flu discount reminyl 8 mg online. The omental bursa is a cul-de-sac that and Helicobacter pylori infection (about 70% of gastric ulcers) are common aggravating factors medicine lake montana best order for reminyl. The mucosa of the stomach is thrown into large treatment tinnitus proven 4mg reminyl, longitudinal folds called rugae and into thousands of microscopic folds and gastric pits lined with a renewing epithelium (simple columnar). Viscera: stomach Greater omentum Inferior vena cava Abdominal aorta Right kidney Parietal peritoneum Spleen Omental foramen Pancreas Duodenum 2 (Common) bile duct Greater Portal triad Hepatic portal vein Lesser omentum omentum B. Viscera: omenta bursa (lesser sac) Omental Hepatic artery proper bursa 1 Cardiac zone Surface epithelial cell 4 Fundic zone 5 Transitional zone Pyloric zone 2 6 Rugae 7 Muscularis mucosa 8 3 Submucosa C. The surface area is increased by the presence of the hepatic portal system (see Plate 5-19). The small intestine circular folds, villi, and microvilli (brush border on the columnar includes the: epithelium). First (superior) part of the duodenum (tethered by the the duodenum is where bile and pancreatic enzymes are added hepatoduodenal ligament containing the common bile to the chyme, which has just arrived from the stomach. The duct, hepatic artery proper, and portal vein) features of the duodenum are summarized below. Circular fold Superior First part; attachment site for hepatoduodenal ligament of lesser omentum n 6. Often it occurs between the ages of 15 and 30 years and presents with abdominal pain, diarrhea, fever, and Jejunum and Ileum other signs and symptoms. The lumen of the bowel is narrowed, mucosal ulcerations are present, and the bowel wall is thick and the jejunum has a larger diameter, thicker walls, greater vascu rubbery; thus it affects the entire thickness of the bowel. Both the jejunum and ileum are suspended in an elaborate mesentery (two folds of peritoneum that convey vessels, lymphatics, and nerves) that originates from the midposterior abdominal wall and tethers the approximately 6 m of small intestine. Plate 8-7 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 271 and 287 Gastrointestinal System Small Intestine 8 Hepatic portal vein Portal triad Hepatic artery proper Superior mesenteric vessels (Common) bile duct Transverse mesocolon Kidney and its cut edges Pylorus 1 Left colic (splenic) flexure Head of pancreas Duodenojejunal flexure and jejunum (cut) 2 Transverse 4 colon (cut) 3 Root of mesentery (cut edges) 1 Superior mesenteric Inferior vena cava artery and vein Abdominal aorta 2 A. Viscera: duodenum 4 3 Right colic artery Ileocolic artery Jejunum Ascending colon Cecum 5 Appendix 7 6 Submucosa Jejunal and ileal (intestinal) arteries Ileum Circular muscle Anastomotic Straight arteries loops (arcades) Longitudinal muscle B. Jejunum (low power) Villus Muscularis mucosa Submucosa 7 Circular muscle Longitudinal muscle Serosa D. Internal anal sphincter (involuntary, smooth muscle; parasympathetic innervation) the large intestine serves primarily to reabsorb water and elec n 9. External anal sphincter (voluntary, skeletal muscle; trolytes from the feces and to store feces until they are elimi somatic innervation) nated from the body. The large intestine has the same layers as the small intestine, but the mucosa does not have villi or circular folds; lymphatic nodules are common. Goblet cells also are Clinical Note: common and secrete mucus, which lubricates the bowel lumen Colonic diverticulosis usually is an acquired herniation of and facilitates the passage of feces. The mucosa has partial colonic mucosa through the muscular wall, creating a divertic folds called plicae semilunares, and the outer longitudinal ulum or little saccule that may contain a fecal deposit or con smooth muscle layer is organized into three thickened bands cretion. This condition is most common in the distal colon and (taeniae coli) that run from the cecum to the rectum and help sigmoid colon and may be caused by exaggerated peristaltic propel the feces along the length of the bowel. Contraction of contractions, increased intraluminal pressure, and/or an intrinsic weakness in the muscular wall. Additionally, the colon is Colorectal cancer is second only to lung cancer in site-specifc studded with small sacs of fat (appendices epiploicae). Risk factors include heredity, diet high in fat, increasing age, infammatory bowel disease, and the pres the terminal end of the large intestine is the rectum and anal ence of polyps. Normally, the anal canal is closed because of the tonic contraction of the internal (smooth muscle) and external (skel etal muscle) anal sphincters. When the rectum is distended by fecal material, the internal sphincter relaxes but defecation does not occur until the voluntary external sphincter is relaxed and the smooth muscles of the distal colon and rectum contract. Plate 8-8 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 276 and 371 Gastrointestinal System Large Intestine 8 Transverse Hepatic mesocolon 3 Splenic flexure flexure Taenia coli 2 Taenia Appendices coli epiploicae Semilunar folds 4 Sigmoid colon Sigmoid mesocolon 1 Rectosigmoidal junction 5 Rectal valves Peritoneal 6 reflection Levator ani muscle 7 Rectal column A. Large intestine structure Rectal sinus Pectinate line Temporary fold 8 (mucosa and submucosa) 8 9 9 Anal canal Hairs and Lining epithelium sweat glands (with goblet cells) in peri-anal skin Lamina propria Mucosa B. Structure of the rectum and anal canal Muscularis mucosa Submucosa Lymphatic nodule Muscularis externa Serosa Taenia coli C. At the porta hepatis) margin of the lobule is the portal triad, made up of a branch of the hepatic artery, a branch of the portal vein, and a bile duct. Gallbladder (green) Ligamentum venosum Ligamentous remnant of fetal ductus venosus, allowing fetal blood from placenta to bypass liver n 3. Round ligament of the liver (yellow) Coronary ligaments Refections of peritoneum from liver to diaphragm 4. Hepatic artery branch (at portal triad) (red) n Bare area Area of liver pressed against diaphragm that 5. Bile duct (at portal triad) (green) Porta hepatis Site at which vessels, ducts, lymphatics, and nerves enter or leave liver n 7. Liver: anterior view 6 Central vein (systemic) Lobule Hepatocyte cords Sinusoids Portal vein branch Portal Hepatic artery branch triad Interlobular bile duct 7 C. The bile, once secreted by the ductal cells secrete fuid with a high bicarbonate content that hepatocyte, takes the following journey: neutralizes the acid entering the duodenum from the stomach. Pancreas the liver produces about 900 ml of bile per day, and between meals it is stored in the gallbladder (capacity of about 30-50 ml), n 6. Main pancreatic duct the duodenum is a mixture of the more dilute bile directly fowing from the liver and the concentrated bile from the gallbladder. The mucosa of the gallbladder is specialized for electrolyte and water absorption, which allows the gallbladder to concentrate the bile. Clinical Note: Gallstones occur in 10% to 20% of the population in developed Exocrine Pancreas countries and usually are precipitates of cholesterol (crystalline cholesterol monohydrate, 80%) or pigment stones (bilirubin the pancreas is both an exocrine and endocrine organ (see calcium salts, 20%). The pancreas lies posterior to the stomach in the sity, female gender, rapid weight loss, estrogenic factors, and foor of the lesser sac (omental bursa) and is a retroperitoneal gallbladder stasis. The stone may pass through the duct system, organ except for the distal tail, which is in contact with the collect in the gallbladder, or block the cystic or common bile spleen. The pancreatic head is nestled within the C-shaped ducts, causing infammation and obstruction to the fow of bile. Most of these cancers arise from the exocrine pancreas, and about 60% are found in the head of the pancreas (can cause obstructive jaundice). Plate 8-10 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 280 and 281 Gastrointestinal System Gallbladder and Exocrine Pancreas 8 2 3 3 2 Liver Proper hepatic artery 4 Duodenum Right gastric artery 4 1 Gastroduodenal artery 4 Cut edge of anterior layer of lesser omentum 1 Stomach Colon 7 5 6 B. Gallbladder: anterior view Epithelium Lamina propria Mucosal fold Crypts Muscle Adventitia Abdominal Inferior aorta Splenic artery vena cava Celiac Stomach (cut) trunk C. Gallbladder: microscopic section Suprarenal gland Spleen Right kidney Tail (retroperitoneal) Pancreas Body Neck Transverse Duodenum colon (cut) Attachment Head of transverse mesocolon Left kidney (retroperitoneal) Transverse colon (cut) Attachment Jejunum of transverse mesocolon Uncinate process of pancreas Superior mesenteric D. Histologically, the portal triad refers to the presence of a branch of the portal vein and hepatic artery, and which of the following structures The cul-de-sac posterior to the stomach and anterior to the pancreas is known by this term. Bile leaving the gallbladder passes down the common bile duct and enters which portion of the gastrointestinal tract As food enters the oral cavity and is mixed with saliva, what enzyme is secreted by the serous glands of the tongue that aids in digestion Pancreas Stomach Pancreas Duodenum Mesentery of the small intestine (jejunum and ileum) 5. Lingual lipase 9 Chapter 9 Urinary System Overview of the Urinary System 9 the urinary system includes the following components: kidney. Urethra the fltrate to a tubule and collecting duct system that, together with the glomerulus, is called the nephron. Regional anatomy of kidney and ureter Inferior Abdominal aorta Duodenum vena cava Duodenojejunal Peritoneum Liver flexure Left renal vein and artery Descending colon 1 1 Pararenal fat (retroperitoneal) Perirenal fat Psoas major muscle B. Proximal ureter displays a distinct cortex (outer layer) and medulla (inner layer). Renal artery Nephrons are located in the outer cortex and in a juxtamedullary region, or the deepest part of the cortex. Renal pyramids (medulla) the tubules of the juxtamedullary nephrons extend deep within the n 7. Major calices to 15 pyramids (collections of tubules), which taper down at their apex to form the papilla, where the urine drips into a minor calyx. Renal pelvis Several minor calices form a major calyx, and several major cali ces empty into a single renal pelvis and the proximal ureter. Renal vein Plate 9-2 See Netter: Atlas of Human Anatomy, 6th Edition, Plates 310 to 312 Urinary System Kidney 9 Right suprarenal gland Left suprarenal gland 1 4 2 4 Superior mesenteric artery Inferior vena cava 3 3 Abdominal aorta A. Kidneys and suprarenal (adrenal) glands Fibrous capsule 5 5 Superior (apical) segmental artery 6 Anterior superior segmental artery 7 Interlobar arteries 6 Inferior suprarenal artery Arcuate arteries Renal 4 papilla 8 9 Anterior inferior segmental artery Arcuate arteries 7 Base of Posterior pyramid segmental arteries Inferior Cortical radiate segmental artery 3 (interlobar) arteries B. These account for only about 10% to 15% of the total nephrons in the hormones stimulate NaCl and water reabsorption by the nephron kidney and are important for concentrating the urine. Juxtamedullary glomerulus (purple) thickness and lined with epithelial cells that are involved in 3. Thin descending and ascending loop of Henle (green) fuid from the loop of Henle, monitors its osmolarity and conveys the fuid to the collecting duct n 5. Endothelium of glomerular capillaries (yellow) cells and virtually all proteins (unless they are smaller in size than n 10. Remember that in the the baroreceptor refex, and its reabsorption is regulated at the average person, about 180 L of fuid is fltered per day (125 ml/ tubular level by aldosterone (secreted by the adrenal cortex), min) and, since plasma accounts for about 3 L of our total blood which stimulates reabsorption. Other factors also play a role but volume, that means that the kidneys flter the blood plasma about water reabsorption is linked to sodium movement until it reaches 60 times per day! Except in the descending limb function, using the colors suggested for each feature: of the loop of Henle, sodium is actively reabsorbed in all tubular 1. Water movement (blue) n regions, and water reabsorption is by diffusion and is depen n 2. About two thirds of the sodium and water is reabsorbed in the proximal tubule; in fact, tubular n 3. Filtrate (green) reabsorption is generally high for nutrients, ions, and water, but n 4. Collecting duct cells capillaries that parallel the renal tubules diffuse or are actively transported into the tubular lumen. The proximal ure urethra, using a different color for each feature: thra in both sexes is lined with transitional epithelium, which then 1. Detrusor muscle of the female bladder wall n gives way to pseudostratifed columnar and stratifed squamous n 2. Trigone in the female and male bladder epithelium as the urethra opens to the exterior. Internal urethral sphincter in the male n to void (urination) and can hold up to 800 to 1000 ml of urine. Membranous urethra the interior, posteroinferior wall of the bladder demonstrates a smooth area called the trigone, demarcated by the two ureteric n 7. External urethral sphincter in the male openings superiorly and the single urethral opening at the base n 8. Normally, the sphinc the detrusor muscle, sending afferent signals to the spinal cord ter mechanism (urethral sphincter) is strong enough to keep levels S2-S4 via the pelvic splanchnic nerves the urine from leaving the bladder. Descriptively, the kidneys do not reside within the abdominal peritoneal cavity nor are they suspended in a mesentery. Renal stones may be passed down the ureter to the bladder but can become lodged at three primary points along their journey to the bladder. At the level of the renal glomerulus, cells envelop the glomerulus to prevent the passage of cells and proteins from being fltered. High levels of this hormone result in the retention (reabsorption) of water in the collecting ducts. Which of the following nerves is critical for maintaining the voluntary urethral sphincter (external sphincter) in males and must be spared, if possible, during pelvic or perineal surgery Which portion of the nephron is critical for monitoring the osmolarity of the tubular fuid At the junction of the renal pelvis and ureter, at the point where the ureter crosses the common iliac vessels, and at the uterovesical junction as it passes through the muscular wall of the bladder. The anterior half of the they produce the female germ cells called ova (oocytes, eggs) diamond-shaped region is the urogenital triangle and it includes and secrete the hormones estrogen and progesterone the vulva or external female genitalia. Uterus (fundus, body, and cervix) (contains ovarian vessels, nerves, lymphatics) and ovarian ligament (tethered to uterus) n 4. Clitoris (crus, body, and glans) n (fallopian the tube and ovary and refects off the uterus tube, oviduct) n 6. Bulb of the vestibule (erectile tissue) the ovaries are suspended from the lateral pelvic walls by the suspensory ligament of the ovary (contains the ovarian neu rovascular elements) and tethered to the uterus medially by the ovarian ligament.

Amputate at longitudinal incision on the dorsal surface to one side of least through the joint proximal to the bone involved medicine 219 order reminyl 4 mg. Do not merely remove part of the involved bone xerostomia medications that cause 4mg reminyl visa, because the infection will spread symptoms pneumonia buy reminyl 4 mg mastercard. The thumb is an exception; spare If a mcp joint is involved medicine 10 day 2 times a day chart purchase cheap reminyl, approach it either from the as much bone as you can symptoms 8 dpo bfp purchase reminyl 4 mg line, and do not amputate if you can dorsal surface (open it from just one side of the extensor avoid doing so treatment toenail fungus reminyl 8mg, because even a stiff stump of a thumb is tendon) medications band order reminyl with amex, or from the plantar surface medications j tube order discount reminyl online. If other joints are involved, approach them from the side where the bone is nearest to the surface. You must however drain septic arthritis and in the soft tissues, especially infections of the pulp of the osteitis, or persistent sinuses may follow. As in the hand, If there is a severe infection, apply a plaster gutter splint rapidly spreading infections are likely to be due to to hold the foot in neutral position. This can be pneumonia, a lung abscess, or the pneumonitis that may follow an inhaled foreign body (usually in a child), or carcinoma of the bronchus (usually in a cigarette smoker or mine worker). A common history is that a week or more before, as the patient was beginning to recover from a chest infection, improvement stopped. He now remains ill, anorexic and febrile, and is starting to lose weight, despite antibiotics. Many kinds of bacteria can be responsible, especially Streptococci, Staphylococci, and E Coli. Antibiotics are only effective in the earliest stages, and may mask the symptoms of an empyema later. The result is that empyemas can remain undetected for years and are often missed in a busy outpatient department. This is sad because you can treat them, so watch out for them, and ask your staff to do so too. To begin with it is thin, like serum; later it thickens and looks like scrambled egg. While it is still thin, aspirate it using a three-way tap or use closed drainage. B, coronal the surfaces of the pleura will not have stuck together at section of the thorax (semischematic). C, ventral aspect of the thorax this stage, so you will have to use an underwater seal to showing the surface projections of the heart and pleurae. The surfaces of the pleura will be stuck so firmly that a pneumothorax will not ensue. If an empyema involves the In order to do this safely, be sure to: whole of the pleural cavity and contains 1l of pus, you (1) Remove the piece of rib from inside its periosteum, should be able to diagnose it clinically. Look for limited so not to injure the vessels and nerve which run just below movement of the chest on the affected side, shifting of the it. Vocal resonance (the sound '99') may be high-pitched at If pus in the pleural cavity remains even longer, the top of the empyema and absent over its lower part. A ruptured diaphragm or hiatus hernia with If radiographs show disappearance of the empyema and stomach or colon in the chest may look like a re-expansion of the lung, cut the suture securing the tube, pyopneumothorax on a radiograph if there is no air and pull it out quickly while closing the hole with a purse visible! If there is fever or malaise, treat with chloramphenicol until sensitivity tests show the need for change. Preferably use the sitting position, leaning over a bed table or a pile of pillows. B, if pus recurs, use an underwater seal drain in a bottle (closed Look these up if you are not sure, and mark them on the drainage). C, if pus becomes thick, resect a rib, and insert a short wide tube (open drainage). Commonly, the posterior axillary line is the and make sure it is in the bottom of the cavity. If pus thickens, so that aspiration needs aspirate gently; turn the tap and discharge the fluid into a 2 or more pulls to fill a 10ml syringe using a 21G needle, receiver. Very rapid decompression of a large pleural withdrawing the tube of the underwater seal drain from the effusion can cause acute mediastinal shift and a vasovagal water. If the effusion recurs, repeat the aspiration but if pus does not stop forming, proceed to closed drainage. Insert an underwater seal 10ml of oily contrast medium before you expose the films. Block the intercostal nerves the pleura, which will prevent the lung collapsing when at the site of your chosen incision, and also one rib above you take the tube out. The instillation of 5-10g of lipiodol and one below it as far posteriorly as possible. Often, the 9th rib in the posterior axillary line is the best, but it may be below this. Do not make the opening too low, because the diaphragm will rise as the pus drains and block the opening. Before incising, confirm by aspiration through more than one intercostal space, that you have chosen the correct rib to remove. Make a 9-15cm vertical incision, extending above and below the selected rib, so that you can more easily resect the rib on either side if necessary. Use a curved Faraboef rougine to strip the periosteum with its attached intercostal muscles from the outer surface of the rib. If you fail to administer adequate anaesthesia, extreme pain may cause a vasovagal attack. Excise a 7-10cm length of rib with an osteotome, rib shears, or a large pair of bone cutters. Open it with a haemostat, explore it with your finger, and remove what semisolid pus you can with sponge holders. Fix a wide radio-opaque tube in the empyema cavity, leaving about 2cm above the skin surface. Fix it with a suture, a safety pin and adhesive strapping to avoid it disappearing into the chest; apply a large gauze and cotton wool dressing. Alternatively, measure how much sterile saline you can run into the remaining cavity. Instil 5-10ml of contrast medium, repeat the radiograph, and if necessary resect another rib. Adequate drainage will eventually achieve a cure if: In sufficient quantity this may embarrass the action of the (1) the lung is not immobilized with thick fibrin, heart (cardiac tamponade) and may be fatal, so you should (2) there is no bronchopleural fistula, and remove it urgently! Presentation with symptoms that immediately this will limit activity, and may cause the drain to be suggest a pericardial effusion is unlikely. In the pericardium, you are mainly draining it to overcome If air comes out with the pus, there is a its mechanical effects. You can confirm this if, accompanied by signs of a low cardiac output with a poor on coughing, pleural irrigating fluid comes up. Once there is tachycardia, a low normal or subnormal blood pressure, no more pus draining, fill the drainage bottle with 500ml and soft heart sounds. Early on you may hear a pericardial sterile water and empty this into the pleural space to clean rub, but the accumulation of fluid soon separates the it. Drain this and repeat the process till the fluid comes out pericardial surfaces and stops the rub. The severity of the signs of cardiac tamponade is saline to make an opaque milky fluid which can still flow, related more to the rate at which fluid accumulates in the and introduce this into the pleural space through the chest pericardium than to the volume of fluid in it. If the patient feels a pleuritic may be obvious, or if fluid has accumulated slowly, it may pain when you do this, the inflammatory reaction may well be difficult. If the intercostal vessels bleed, encircle them with a (2);Although pulsus paradoxus strongly suggests a needle and thread. Avoid tying the nerve because this is pericardial effusion, not all patients show it. If you have difficulty, transfix the vessels with a (3);The radiographic finding of a large globular heart can ligature, so that they are compressed against the stump of also be due to gross cardiac enlargement without there the rib which remains. Ultrasound is much more reliable, and can also give you If the empyema fails to heal: information about the thickness of the pericardium and the (1) You may have put the drainage tube too high or too far thickness of the fluid in the sac. The great danger in putting a needle into the pericardial (3) You may have put it in too late. Depending on what is causing the pericarditis, you may see basal shadows in the lungs, Suggesting viral myocarditis: an influenza-like illness or pneumonia obscuring the heart. These are some causes of a large heart without fluid in the pericardial cavity: Suggesting rheumatic heart disease (common): valvular lesions; these are usually easily diagnosed by hearing heart murmurs. Have the full resuscitation equipment available: laryngoscope, tracheal tubes, a sucker, oxygen, and an anaesthetic machine or an Ambu bag. An 16G (or 12G for thick pus) long cannula, a 3-way tap, and a 20 or 50ml syringe. With the patient propped to the cannula and insert this in the epigastrium up 45o, incline the needle horizontally and direct it 10o towards the immediately to the left of the xiphisternum. In this way, if it does puncture the heart, it is more likely to meet o With the patient propped up at 45 push the needle the thicker left ventricle than the thinner right auricle. If there is a sudden deterioration with multiple or Streptococcus pneumoniae if solitary in a absence of a pulse: lower lobe, (1) Immediately remove the cannula. Start external cardiac massage at a rate of 30 beats to (7) an infected pulmonary embolus 1 ventilation. Only when the situation is under Drainage, however, may not be successful if the bronchus control, should you intubate and ventilate the patient is blocked by a foreign body or carcinoma: it may be mechanically. However, some lung abscesses, especially in xiphisternum; incise the linea alba and proceed upwards in children, need to be removed by pulmonary lobectomy. Put two stay sutures through the pericardium and lift this off the heart; then cautiously incise the pericardium, enlarge the hole and insert a Ch16 balloon catheter for thin pus and a Ch22 one for thick pus. If you leave the drain in long, it may erode the friable myocardium with disastrous results! Recurrence of pyopericardium is common, especially if the pus is thick and looks like scrambled egg! In this situation a partial pericardiectomy through a left lateral thoracotomy, avoiding the phrenic nerve, is advisable, and is probably more effective, if you can arrange it. For example, there may be the symptoms of peptic ulceration, appendicitis, cholecystitis or typhoid fever, but no involvement of the peritoneum. Abdominal sepsis is a common and life threatening complication following severe infection, necrosis, (2) Localized peritonitis. A mass may form, but the toxic Not infrequently, abdominal sepsis occurs after medical effects of sepsis will be absent. Pus forms, but this is sealed off, not usually by a fibrous In the majority of cases the mainstay of treatment is the capsule from the rest of the abdominal cavity, but by loops expeditious removal of bacteria and dead tissue; of bowel and/or omentum which are stuck to one another early recognition of the condition is therefore imperative. The mass is generally bigger than Abdominal sepsis occurs in the form of either generalized in stage 2 above, and is associated with toxic symptoms. One form can evolve into the It is still, if left untreated, likely to develop into spreading other. Occasionally the abscess may be walled off entirely from the rest of the abdominal contents, the common sites for localized peritonitis are (10-6): or even be retroperitoneal (6. This abscess may (1);On the right side: subphrenic, subhepatic, ileocaecal however rupture and sepsis may then spread. Localized accumulation of fluid in the peritoneum is cavity, particularly in the pelvis and under the diaphragm. Also, the nomenclature with regard to cavity, more collections may still form postoperatively. This fluid, and is extremely porous to bacteria; thus septicaemia and that which is lost into the abdominal cavity, depletes quickly ensues. So it is not surprising that the mortality the circulating blood volume so the urine output falls, and from generalized peritonitis is at best 10%, even in good the pulse rate rises. Bacteria, both aerobic and anaerobic, circulation fails, and shock results, but pain may diminish can be released from the bowel when it perforates but also as ascites collects and dilutes the peritoneal irritation. When there is chemical history and a full examination are extremely important: contamination of the peritoneum from blood, stomach the commonest mistake is to leave out some of the contents, bile, pancreatic juice, urine or cyst fluid, essential parts of both. Traumatic or surgical diagnosis, and examination should merely confirm or intervention obviously allows a route for bacteria to refute it. After the operation, if the diagnosis is a surprise, contamination of the abdominal cavity, when you perform think back to distinguish which features of the history were a laparotomy. Not to examine the patient carefully and Pain may also be referred from the diseased area to the systematically, admit him and monitor him carefully and other parts of the body that are derived from the same to look at him again if you are not clear of the diagnosis, spinal segment. Not to make and record a diagnosis and a differential under the diaphragm may present with pain in the diagnosis, especially if you are handing over to a shoulder. To forget that many medical conditions, especially There can be pain of more than one kind. For example, pneumonia (by causing diaphragmatic pain) can mimic an when the lumen of the appendix is obstructed, there is acute abdomen. If the appendix becomes probability of a particular diagnosis gangrenous, there is ischaemic pain of type (2). Not to make adequate allowance for the late case whose history is obscured, whose mind is clouded, and whose signs are altered. Constitutional disturbances such as anorexia, nausea and vomiting, the inability to pass flatus in the presence of either constipation or diarrhoea and frequency of micturition are common. In general, the patient with peritonitis is weak, thirsty, anorexic and nauseated. B, (6) kidney and pancreatic pain its correct interpretation will lead you towards the cause. C, (8) diaphragmatic pain is frequently is highly significant and demands you find out the cause! Suddenly: Rupture of duodenal ulcer or bowel (3) A colicky pain is due to obstruction of either bowel, Torsion of testicle, bowel or ovarian cyst biliary tree or urinary tract: it comes in waves and spasms Mesenteric vessel occlusion and often makes the patient move about restlessly. Was it before or after the give you some clues, especially with intestinal obstruction normal time If, in a child, the rate in health, change in girth is twice normal, and the alae nasi are flaring, pneumonia Severe illness with fever Typhoid is likely. Vigorous the temperature is raised; if it is not, the inflammation is massage of the abdomen may cause bowel injury! Ask the patient to point to where the (which you may note simply by a difficulty in speaking), pain started, to where it is now, and to where it is worst. Tachycardia is common as is sweating whereby the Look for distension due to gas, or fluid: test for shifting extremities may be warm or cold. Initially in peritonitis the abdomen is tympanitic, present and infants as well as the aged may have later it will fill with ascitic fluid. Peritonitis the general condition may be surprisingly normal anywhere may splint all or part of the abdomen, and stops especially early on in the disease. If he is restless, Visible peristalsis means there is obstruction not paralytic suspect cerebral hypoxia, due to hypovolaemia. Look for a dry tongue and lack of skin turgor Expose the whole abdomen including genitalia & look at (dehydration), pale conjunctivae (anaemia), mouth signs of the groins: there may be an obstructed irreducible hernia. If extending Deathly pale with gasping Severe bleeding the hips causes abdominal pain, this is a reliable sign of respiration. Lay your hand flat on the abdomen, and keep your fingers dry, skin elasticity reduced Intestinal obstruction. Your hand must (The Hippocratic facies is a combination of all of these; be warm, gentle, patient, and sensitive. Tachycardia is usual in peritonitis, and early in Then, if necessary use deep palpation. The pulse of typhoid fever is Wincing (10-1D) on pressure of the abdomen is a very no longer slow after the ileum has perforated. If the abdomen is rigid like a board, this is proof keeping the hips and knees flexed, fearing to cough, of generalized peritonitis, especially that due to a sneeze or move. But if peritonitis is localized, straight one minute and doubled up the next, he has colic rebound tenderness is a good indication as to which parts and not peritonitis. Get him to lie on the opposite side to where the pain is, Find where the area of greatest tenderness is. It will be and extend the thigh on the affected side to its fullest easier to find if there is no generalized guarding, and is a extent. If this is painful, there is some inflammatory lesion useful clue to the organ involved. If rotating the flexed thigh so as to peritonitis, especially if ascites is present. The peritonitis is advanced and ascitic fluid dilutes the the thoracic percussion test. Percuss gently with your fist peritoneal irritation: so as he gets more ill, the tenderness over the lower chest wall. Percuss for liver dullness in the right nipple line from the (5);He has been given narcotic analgesia, especially 5th rib to below the costal margin. If liver dullness is postoperatively, or is paraplegic with a sensory level at the absent, there is probably free gas in the abdominal cavity.

De bedrijfsarts zou in de begeleiding van clienten opiaatgebruik moeten aanpakken medications in carry on luggage purchase reminyl with mastercard. Recente literatuur spreekt zich veel duidelijker uit tegen opiaatgebruik bij aspecifieke lage rugpijn medicine daughter discount reminyl uk. Vanwege de grote hoeveelheid gevonden studies is er voor gekozen alleen systematische reviews over de periode 2010-2015 the includeren (n=89) medicine 600 mg cheap reminyl 8mg on-line. Als er voor bepaalde soorten interventies geen systematische review beschikbaar was voor deze periode treatment 1st degree av block order genuine reminyl line, dan is voor deze interventie ook de literatuur tussen 2005 en 2010 geraadpleegd medications kidney stones cheap reminyl 8mg mastercard. De interventies en behandelingen beschreven in dit hoofdstuk zijn gericht op treatment math definition purchase reminyl cheap, en hebben als primaire doel medicine you can take while breastfeeding buy reminyl without prescription, het behandelen van de aandoening medications reactions buy reminyl 4mg lowest price, het verlichten van symptomen, pijnvermindering, herstel van (spier)functie, kracht of uithoudingsvermogen. Dit kan voldoende zijn om aan het werk the blijven of terug the keren naar het werk mogelijk the maken, maar dat is hier een indirecte of secundaire uitkomst. De interventies zijn ingedeeld op het belangrijkste aangrijpingspunt of op de uitkomstmaat die ze nastreven: A. Herstel van (spier)functie Veel interventies op het gebied van aspecifieke rugpijn hebben als uitgangspunt dat er bij mensen met aspecifieke lage rugpijn sprake is van een verstoring in (spier)functie, waardoor de rugpijn aanhoudt of recidiveert. De oorzaak van die verstoring wordt op verschillende manieren verklaard en de oplossingen, uitgewerkt in verscheidene interventies, zijn zeer divers. Verstoorde functie manifesteert zich meestal in spierspanning, welke in veel therapievormen wordt gerelateerd aan de pijn. Herstel van functie kan bijvoorbeeld betekenen het trainen van de coordinatie van stabiliserende spieren, ontspanning, trainen van de ademhaling of behandelen van triggerpoints. De verklaring voor de pijn wordt hier gezocht in slechte motorcontrole van stabiliserende spieren van de wervelkolom. De musculus transversus abdominus, multifidus en erector spinae lijken de belangrijkste lumbale stabilisatoren the zijn en hun rol is aangetoond in onderzoek. In het bieden van een mogelijke verklaring voor aspecifieke lage rugpijn kan dit model worden uitgelegd aan de client. In vergelijking met alternatieve vormen van lichaamsoefeningen was er geen statistisch of klinisch significant verschil. Enkele studies toonden aan dat de doorsnede en de dikte van de multifidus spier kan worden verhoogd door het activeren van deze spier, waarna de motorische controle en de statische en dynamische belastingen van de spier verbeterde. Uit het literatuuronderzoek bleek verder dat specifieke oefeningen de symmetrie van de multifidus spier kunnen verbeteren. De nadruk van de methode ligt bij de spieren die ervoor zorgen dat het lichaam in de correcte balans staat en de wervelkolom ondersteunen. Er is de laatste jaren een ware hausse aan wetenschappelijk onderzoek gepubliceerd over de effectiviteit van Pilates. De resultaten van een aantal recente systematische literatuurstudies en meta-analyses worden hier kort beschreven. In een systematisch literatuuronderzoek met meta-analyse werd het effect van Pilates oefeningen op pijn en beperkingen bij mensen met aanhoudende aspecifieke lage rugpijn onderzocht (Lim. Hieruit bleek dat op Pilates gebaseerde oefeningen effectiever zijn dan minimale interventie voor pijnbestrijding. Er is echter geen bewijs gevonden dat Pilates effectiever is dan andere vormen van oefeningen voor vermindering van pijn en beperkingen bij patienten met aanhoudende aspecifieke lage rugpijn. De bestaande studies waren echter van relatief lage kwaliteit en de heterogeniteit van gepoolde studies was groot. Pilates bleek effectiever voor pijnbestrijding en afname van beperkingen vergeleken met een minimale behandeling. Door de aanwezigheid van co-interventies en de lage methodologische kwaliteit van sommige onderzoeken, moeten deze conclusies voorzichtig worden geinterpreteerd. Daarnaast werd geconcludeerd dat Pilates even effectief is als massagetherapie en andere vormen van oefeningen. Het effect van proprioceptieve oefeningen op pijn en functie is onderzocht bij rugpatienten (McCaskey. Gevonden interventies bestonden uit het onderscheiden van somatosensorische stimuli op de rug, evenwichtsoefeningen op instabiele ondergrond en herpositioneringsoefeningen met hoofd-oog coordinatie. Er bleken weinig relevante studies van goede kwaliteit over proprioceptieve oefeningen the bestaan. De auteurs concluderen dat er geen consistent voordeel bestaat in het toevoegen van proprioceptieve interventies aan lage rugpijn revalidatie en functioneel herstel. Het impliceert afwisselende periodes van begeleide weerstand en ontspanning van spieren. Grotere methodologisch verantwoorde studies zijn nodig om deze vraag the beantwoorden. Fysieke oefeningen In een systematisch literatuuronderzoek met meta-analyse werd onderzocht welke oefeningen het meest effectief zijn bij chronische lage rugpijn (Searle. Uit de meta-analyse bleek dat oefeningen resulteerden in significant lagere chronische lage rugpijn in vergelijking tot een controlegroep of een groep die een andere behandeling onderging. De effecten zijn echter klein en het is onduidelijk welke groepen het meest profiteren van een specifieke behandeling (Van Middelkoop. De auteurs concluderen dat tractie, alleen of in combinatie met andere behandelingen, weinig tot geen effect heeft op pijnintensiteit, functionele status, algehele verbetering en terugkeer naar werk bij mensen met lage rugpijn. Tot op heden kan het gebruik van tractie bij aspecifieke lage rugpijn niet worden aanbevolen. Hieruit bleek dat er matig bewijs is dat manipulaties een significant effect hebben op pijnbestrijding onmiddellijk na de behandeling en bewijs van lage kwaliteit dat manipulaties een significant effect hebben op pijnvermindering op korte termijn follow-up. Er is bewijs van zeer lage kwaliteit dat manipulaties geen statistisch significant effect hebben op beperkingen en het ervaren herstel. De auteurs concluderen dat manipulaties een klinisch relevant effect hebben op de pijn, maar niet op beperking of ervaren herstel. Bovendien werd in een studie minder medicatiegebruik, minder gebruik van gezondheidszorg en minder ziekteverzuim in de interventiegroep gerapporteerd (Kuczynski. Posadzki (2012) daarentegen concludeerde in een uitgebreide literatuurstudie dat spinale manipulatie niet effectief is voor pijnbestrijding (zie ook Rubinstein. Tenslotte werd de effectiviteit van spinale manipulatie versus oefeningen onderzocht bij patienten met lage rugpijn in een ander systematisch literatuuronderzoek (Merepeza, 2014). Op basis van de 45 uitkomsten van deze systematische review is er geen sluitend bewijs dat aantoont dat manipulaties effectiever zijn dan oefeningen of andersom. Osteopathie Osteopaten zijn gezondheidbeoefenaars die rugpatienten diagnosticeren en behandelen met behulp van een complex geheel van interventies, waaronder manuele therapie. Matige kwaliteit bewijs werd gevonden voor een significant effect van osteopathie op pijn en functionele status in acute aspecifieke lage rugpijn. Bij chronische aspecifieke rugpijn was er matige kwaliteit bewijs voor de effectiviteit van osteopathie voor pijnvermindering en verbetering van functionele status. Geconcludeerd wordt dat er bij follow-up van 3 maanden klinisch relevante effecten van osteopatie zijn gevonden voor het verminderen van pijn en verbetering van de functionele status bij patienten met acute en chronische aspecifieke lage rugpijn. In een andere systematische literatuurstudie (Orrock & Myers, 2013) werd de effectiviteit van osteopathie (manueel therapeutische interventie door osteopaat) onderzocht bij patienten met chronische aspecifieke lage rugpijn. Een studie concludeerde dat de osteopathische interventie even effectief was als een placebo interventie, en de andere suggereert gelijkwaardige effectiviteit van de osteopathische interventie, lichaamsbeweging en fysiotherapie. Meer onderzoek is nodig om betrouwbare uitspraken the kunnen doen over de effectiviteit van osteopathie bij rugpijn. Chiropractie Chiropractors maken gebruik van een combinatie van interventies om mensen met lage rugpijn the behandelen, maar er is weinig bekend over de effecten van deze zorg. Voor acute en subacute lage rugpijn verbeterden chiropractie interventies pijn op de korte en middellange termijn in vergelijking met andere behandelingen, maar er was geen significant verschil in langdurige pijn. De korte termijn vermindering in beperkingen was groter in de chiropractie groep in vergelijking met andere therapieen. De auteurs concluderen dat gecombineerde chiropractie interventies op de korte termijn pijn en beperkingen enigszins kunnen verminderen en op de middellange termijn bij acute/subacute lage rugpijn de pijn kunnen verminderen. Echter, er is momenteel geen bewijs dat chiropractie interventies effectiever zijn voor vermindering van pijn of beperkingen vergeleken met andere interventies. Pilates-based exercise for persistent, non-specific low back pain and associated functional disability: a meta-analysis with meta-regression. Core stabilization exercise prescription, part 2: a systematic review of motor control and general (global) exercise rehabilitation approaches for patients with low back pain. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. Experimental muscle pain changes feedforward postural responses of the trunk muscles. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Effects of Pilates-based exercises on pain and disability in individuals with persistent nonspecific low back pain: a systematic review with meta-analysis. Effects of proprioceptive exercises on pain and function in chronic neck and low back pain rehabilitation: a systematic literature review. Effects of spinal manipulation versus therapeutic exercise on adults with chronic low back pain: a literature review. Efficacy of the Pilates method for pain and disability in patients with chronic nonspecific low back pain: a systematic review with meta-analysis. Osteopathic intervention in chronic non-specific low back pain: a systematic review. Effects of Pilates exercise programs in people with chronic low back pain: a systematic review. Comparing the Pilates method with no exercise or lumbar stabilization for pain and functionality in patients with chronic low back pain: systematic review and meta-analysis. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Is manipulative therapy more effective than sham manipulation in adults: a systematic review and meta-analysis. Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomised controlled trials. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance A meta-analysis of core stability exercise versus general exercise for chronic low back pain. The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review. Pijnmedicatie bij lage rugpijn Er zijn verschillende pijnstillers van verschillende sterkte. Pijnmedicatie wordt onderverdeeld in 4 categorieen al naar gelang sterkte en werking op de analgetische pijnladder. Van de zeven geincludeerde studies vond geen enkele studie een statistisch significant verschil ten gunste van paracetamol en er blijkt onvoldoende bewijs the zijn voor gebruik van paracetamol in de behandeling van lage rugklachten. Het gebruik van opiaten door mensen met chronische pijn, waaronder rugpijn, neemt toe. Zij concluderen dat opiaten de terugkeer naar werk niet versnellen en functionele uitkomsten niet verbeteren bij mensen met acute rugpijn. Voor chronische rugpijn geldt dat er nauwelijks bewijs is dat opiaten effect hebben. Opiaten hebben op de korte termijn wel meer effect op pijnvermindering dan placebo, maar de voordelen voor functieverbetering zijn onduidelijk (zie ook Chaparro. Voor tapentadol werd een positief effect gevonden op pijnvermindering en een vermindering van bijwerkingen en verbetering van verdraagzaamheid ten opzichte van oxycodon (Santos. De mate van pijnvermindering bij chronische aandoeningen (waaronder niet kanker) is ongeveer 30%. Korte termijn bijwerkingen zijn constipatie, misselijkheid, verdoving en hogere kans op vallen met breuk als gevolg. Screening voor hoogrisico-patienten, behandelovereenkomsten en urinetesten hebben het aantal voorgeschreven recepten, misbruik of overdoses niet verminderd. Anti-depressiva In een systematische review met betrekking tot medicatie voor chronische lage rugklachten, concludeerden White. Bovendien bleken anti-depressiva ook geen effect the hebben op vermindering van depressie in een populatie met chronische lage rugklachten (Urquhart. Drug therapy for the treatment of chronic nonspecific low back pain: systematic review and meta-analysis. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. Are non-steroidal anti inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain Cognitief gedragsmatige therapieen Met de zoekstrategie zijn verschillende artikelen gevonden met betrekking tot cognitief gedragsmatige therapieen voor aspecifieke lage rugklachten in de periode van 2005 tot en met 2015. Een systematische review is geexcludeerd, omdat het een Nederlandstalige studie betrof. Onder de overgebleven studies bevonden zich zes relevante reviews over de periode van 2007-2015. Matig bewijs werd gevonden voor een effect van multidisciplinaire revalidatie op pijn en de mate van beperkingen vergeleken met gebruikelijke zorg. Bewijs van lage kwaliteit (door een grote heterogeniteit) werd gevonden voor een effect van multidisciplinaire revalidatie op pijn en de mate van beperkingen vergeleken met fysieke behandelingen. Matig bewijs werd gevonden voor een effect van multidisciplinaire revalidatie op werkhervatting een jaar na afloop van de interventie vergeleken met fysieke behandelingen. Matig bewijs werd gevonden dat multidisciplinaire revalidatie de kans op werkhervatting niet verhoogt vergeleken met gebruikelijke zorg. Multidisciplinaire revalidatie vergeleken met chirurgische ingrepen leverden nauwelijks verschil op in uitkomsten en een verhoogd risico op negatieve effecten door chirurgische ingrepen. Voor werkuitkomsten lijkt multidisciplinaire revalidatie meer effectief dan fysieke behandeling, maar dit geldt niet voor de vergelijking met gebruikelijke zorg (Kamper. Multidisciplinaire behandelingen, waarin een psychologische component was opgenomen en die werden vergeleken met een actieve controlegroep, hadden ook positieve lange termijn effecten op werkhervatting (Hoffman. Multidisciplinaire rugtraining heeft op de lange termijn een positief effect op arbeidsparticipatie en de kwaliteit van leven van patienten met aspecifieke chronische lage rugpijn. Dit effect wordt niet gevonden voor pijnvermindering en functioneren in algemeen dagelijks leven. Cognitieve gedragstherapie Voor cognitieve gedragstherapie werd bewijs van lage kwaliteit gevonden voor een matig effect op pijn, functioneren, kwaliteit van leven, werkgerelateerde uitkomsten en zorggebruik (Ramond Roquin. Ook werden positieve effecten gevonden op werkgerelateerde uitkomsten, zoals ziekteverzuim en werkhervatting (Sveinsdottir. Actieve revalidatie (fysieke oefeningen gecombineerd met principes van cognitieve gedragstherapie) was effectiever dan gebruikelijke zorg door de huisarts in het verminderen van beperkingen in activiteiten door patienten met een hoog bewegingsgerelateerde angst (Kent en Kjaer, 2012). Deze interventies bleken niet minder effectief dan andere interventies in het verminderen van beperkingen. Matig bewijs werd gevonden dat deze 50 interventies effectiever zijn dan andere gedragsmatige interventies in het verminderen van lange termijn beperkingen in patienten met chronische lage rugklachten. Tenslotte werd matig bewijs gevonden dat deze interventies effectiever zijn dan een placebo-interventie in het verminderen van korte termijn pijn in patienten met subacute lage rugklachten (Bunzli. Graded activity en graded exposure In een systematisch literatuuronderzoek werd de effectiviteit van graded activity en graded exposure onderzocht bij patienten met aspecifieke lage rugpijn (Lopez-de-Uralde-Villanueva. Graded activity was effectiever voor vermindering van beperkingen dan standaardzorg (specialist of fysiotherapeut) op korte en lange termijn. Graded activity bleek op korte termijn minder effectief voor verminderen van beperkingen en catastroferen dan graded exposure. Er is matig bewijs dat graded exposure effectiever is voor vermindering van catastroferen dan graded activity. Graded activity is op korte termijn iets effectiever dan minimale interventie en niet effectiever dan andere vormen van oefeningen. Fysiotherapie aangevuld met graded activity of graded exposure resulteerde in vergelijkbare klinische resultaten voor de intensiteit van de pijn en beperkingen (George. Niet de gevolgde interventie was geassocieerd met de uitkomsten, maar de mate van depressie en catastroferen. In hoeverre deze interventie effectief was in relatie tot arbeidsparticipatie is niet onderzocht. Physiotherapy-provided operant conditioning in the management of low back pain disability: A systematic review. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain a systematic review. Lopez-de-Uralde-Villanueva I, Munoz-Garcia D, Gil-Martinez A, Pardo-Montero J, Munoz-Plata R, Angulo-Diaz-Parreno S, Gomez-Martinez M, La Touche R. A Systematic Review and Meta-Analysis on the Effectiveness of Graded Activity and Graded Exposure for Chronic Nonspecific Low Back Pain. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care-a systematic review.

The non modifiable factors age medications 247 buy reminyl amex, gender treatment lead poisoning purchase online reminyl, education were important in several instruments: higher age was associated with higher functional limitations in nine populations treatment zinc deficiency buy cheap reminyl 8mg online, in one study medicine you cannot take with grapefruit purchase reminyl 4mg on line, younger age was related with functional limitations and one study showed a U shaped relationship between age and function medicine x topol 2015 generic reminyl 8 mg with visa. Furthermore medicinenetcom purchase reminyl with amex, diverse medical interventions were related with functional limitations 13 Horn et al medications going generic in 2016 buy 4mg reminyl. In Thirteen out of the 18 intensity medicine while pregnant cheap reminyl 8 mg with mastercard, pain-related disability measures were predictive of work Overall, the explained variance was modest. A performance-based lifting test Simulator, one the ErgoKit, policies and practices. The other five studies used tests or combinations of like a step test, a lift test, or a trunk strength tester. Two studies combined the results of the performance-based test with non-performance based outcomes like pain and Waddell signs 15 van der Meer et al. Radiating pain, specialist for treatment to an and body functions, play a depression worse. The total tasks, performed by patients patients and those experiencing a most tasks. This might indicate that these tasks are more objectively a high percentage of the assessed by six capacity walked slower. As expected, the level of pain contributed significantly and inversely to the walking and stair climbing tasks. However, written interview reports to information on the patient: between the groups in scores (mean percentage approximately there was a significant difference in scores on assessed work assess work limitations in 30 the first group received only given on the work limitation 80%). The physicians who received limitation items compared with medical history-taking alone. Patients both groups of physicians, differences in agreement percentages and content validity, and it appears to be acceptable to both months of sick leave (n=62). It did not improve inter-observer interviewed and examined and differences between the eligibility for a disability benefit. In 9 agreement beyond that of usual interview procedures used in the either by two physicians groups in terms of the scores out of 21 items the physicians of the Netherlands. In addition, between the two groups, no differences were found as to the satisfaction of patients concerning the behavioral aspects of the physicians. All four instruments have limitations regarding functional limitations in validity, construct validity, functional limitations. However, a improve the symmetry of the multifidus (n=127) multifidus muscles muscle few studies showed that the cross-sectional area and muscle. The difference between groups was number of high methodological quality of length of time and 24 studies (n=2, 359) clinically insignificant. When compared with alternative available studies, at long term follow-up, (n=4, 617). However, no significant severity were observed between patients who differences were observed between core stability exercise engaged in core stability exercise versus those and general exercise in reducing pain at 6 months [mean who engaged in general exercise. The statistical the low methodological quality of some model used did not detect any predictor variable. However, Pilates that Pilates method exercises are more nonspecific low were considered eligible, was better than a minimal intervention for reducing short effective than minimal intervention in back pain and seven trials were term pain and disability (pain: pooled mean difference=1. One study administered an exercise pain and disability, whereas another reported (n=1, 373) exercises (n = 6 trials) and protocol with Pilates method-based floor exercises, initially that Pilates method reduces pain when Pilates method versus no performed as static exercises protocol; they progressed to compared with minimal treatments, but not treatment group or minimal dynamic exercises involving hip extension movements and disability. In contrast, another review intervention for short-term then to exercises on the reformer, with 12 one-hour concluded that Pilates method is ineffective in pain (n = 9 trials); the sessions conducted in addition to a home-based program of reducing pain and disability, and yet two other therapeutic effect of the 15 minutes, 6 days a week for 4 weeks. Finally another review asserted randomized cohorts (n = disability, which was maintained over a 12-month follow-up that Pilates method was better than a minimal 5); and analysis of reviews period. Another study compared the Pilates method with a intervention for reducing pain and disability in (n = 9). Another study compared the term pain reduction Pilates method (15 sessions) with no exercise. After intervention, the Pilates group showed a significant decrease in pain compared to the no-Pilates group. After intervention, the Pilates group showed a significant decrease in pain (P < 0. Another study compared Pilates method treatment with giving patients an educational booklet. Statistical differences were also found between groups regarding the use of pain medication at 45, 90, and 180 days of exercise program (P < 0. Another study confirmed that 8 weeks of specific Pilates method for trunk had reduced the disability and the pain significantly. Pilates exercise offers equivalent n = 9 significant differences in improvements in pain and improvements to massage therapy and other Pilates exercise vs. Future research should massage therapy: n=1 other forms of exercise at any time period. Three main that PrThis no more effective than conventional summary of the evidence suggests that there back pain directions of PrT were physiotherapy. Low quality evidence suggests PrThis inferior is no consistent benefit in adding PrT to neck (n=1, 380) identified: Discriminatory to educational and behavioural approaches. There was very low quality evidence that the Four studies had a low risk days on sick leave were reduced by post-treatment of bias, one study a high exercises (Mean Difference 4. One study reported on pain and disability at therapy is effective at reducing pain and the total number short-term follow-up, and found no statistically significant function in the treatment of chronic low back of included differences between the exercise group and the control pain. There is no evidence that one particular participants is group receiving home exercises. One small and it remains unclear which subgroups study found a statistically significant difference at of patients benefit most from a specific type of intermediate follow-up for pain relief for the exercise group treatment. Separate exploratory subgroup analysis chronic low back pain and that showed a significant effect for strength/ resistance and cardiorespiratory and combined exercise coordination/stabilisation programs. A review of 15 moderate Physiotherapy Pain Trials which reported on pain scales at 6-month follow-up Exercise programmes are effective for chronic Grimmer the total number quality trials. There was unconvincing evidence of exercise effectiveness on pain scales after this time. Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively. In four studies manipulative therapy (and in one case Based on the findings of this systematic al. Comparative spinal manipulation by physical therapists in Efficiency of treatment groups consisted of use of a stationary bicycle, lumbar clinical practice. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time. The third study found both clearly favours spinal manipulation or exercise older) with low interventions offering equal effects in the long term. More back pain studies are needed to further explore which persisting 12 intervention is more effective. Sample on therapy directed perceived recovery quality of evidence (from very low to moderate) suggesting than other recommended therapies. There is low level of evidence that the subgroup of patients with musculoskeletal manipulative therapy has a significant effect in adults on disorders. No serious adverse events were reported in the manipulative therapy or sham group. The trials used effect of the manual therapy intervention specific low back Patient satisfaction different comparators with regards to the primary applied by osteopathic clinicians in adults with pain (n=330). Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice. Strong trials in this review had high drop-out rates, consumption, opioids (morphine, hydromorphone, oxycodone, were of short duration, and had limited addiction or overdose oxymorphone, and tapentadol), examined in six trials (1887 interpretability of functional improvement. All but one of the trials problems with the previous research have provided imprecise estimates of the effects of treatment been highlighted by this review. These with confidence intervals spanning clinically important problems include the lack of large high quality beneficial and also harmful effects of paracetamol. No trial trials, inadequate reporting of methods and reported a statistically significant difference in favor of results, results that appear implausible and paracetamol. The results of this review demonstrate a clear need for further quality research into the efficacy of paracetamol in patients with low back pain. The total Pain remains unclear, and surveillance data have shown adverse effects are most likely to receive America number of Complications markedly increased rates of opioid overdose and addiction. Thus, support for alternative included patients Side effects Long term complications of opioid treatment include falls, treatments should be strengthened. These results support the spinal pain (neck trials) the management of Quality of life Adverse difference 0. There was moderate-to-high interventions in efficacy outcomes, high both) heterogeneity for the efficacy outcome estimates. There was moderate-to high heterogeneity for most efficacy (except for the primary outcome) and safety outcome estimates. The back pain should not be treated with without leg pain qualitative analyses found conflicting evidence on the effect antidepressants; furthermore, there is of antidepressants on pain intensity in chronic low back evidence for their use in other forms of pain, and no clear evidence that antidepressants reduce chronic pain. Two pooled analyses showed no difference in pain relief between different types of antidepressants and placebo. Our findings were not altered by the sensitivity analyses, which varied the risk of bias allowed for inclusion in the meta-analyses to allow data from additional trials to be examined. Multidisciplinary biopsychosocial rehabilitation and Cognitive behavioural therapy) 40 Bunzli et al. Netherlands years) with randomized controlled training (including one Experienced pain quality studies found a positive effect on at least one of the has a positive effect on work participation in nonspecific trials. No effectiveness was found behavioral, for experienced pain and functional status. The intensity of educational or social) the intervention seems to have no substantial influence on the effectiveness of the intervention. Cognitive-behavioral and self-regulatory pain of 3 months approaches, in the pain-specific treatments were specifically found to be efficacious. Seven trials provided moderate quality evidence multidisciplinary that multidisciplinary rehabilitation does not improve the intervention odds of being at work (odds ratio 1. Graded exposure was modification, and they do not provide consistent duration, which such as fear limitation. Secondary not more effective than Treatment-Based Classification only evidence supporting such targeting. While it was categorised avoidance beliefs, outcome measures and as the level of fear did not change this result, the might seem intuitive that the targeting of as acute (less anxiety, depression or were psychosocial targeting of graded exposure to people with high psychosocial interventions would be effective, than 6 weeks), catastrophisation factors (fear movement-related fear was not useful. Active rehabilitation this review did not find consistent evidence to sub-acute (6-12 avoidance, anxiety, was either no more or less effective than manual therapy in support this notion. There was beliefs and coping skills, with disappointing in primary care Health care use lack of evidence concerning the effectiveness of individual results. The total (n=46) cognitive and Pain coping worry, catastrophizing, depression, disability, disabling of relevant cognitive, behavioral and physical number of behavioral Negative affect attitudes and beliefs, and stress, and increased coping, variables. It has also demonstrated effects on (physical treatments/exercise, acceptance and occupational and economic outcomes in terms of cost information/education, and lumbar spinal fusion commitment therapy) effectiveness, health care visits, reduction in sick days/work surgery, biofeedback, operant behavioral compared to wait-list days lost, and return to work. States of participating in a trial supplemented with Disability observed for pain intensity and disability at discharge. The exercise or graded exposure resulted in America multidisciplinary graded exercise rate of improvement did not differ based on behavioral equivalent clinical outcomes for pain intensity rehabilitation (n=15) or graded intervention received (P>. The overall treatment effects program for exposure (n=18) Overall, 50% of patients met criterion for minimally were modest in this setting. Instead of being chronic low important change for pain intensity, while 30% met this associated with a specific behavioral back pain criterion for disability. Change in depressive symptoms was intervention, reductions in pain and disability associated with change in pain intensity, while change in were associated with reductions in depressive pain catastrophizing was associated with change in symptoms and pain catastrophizing, disability. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Patients in Function the time points for any of the similar effects for patients with chronic nonspecific both groups received Disability outcomes studied. For example, the effect for pain at 2 nonspecific low back low back pain 14 sessions of Global impression of months was 0. Educative interventions Reassurance 52 Hasenbring 2015 Germany Patients with low Short narrative systematic Reassurance of Prognosis of low back Recovery improved in a combination of communication of No evidence is presented. Reassurance of patients in providers need effective reassurance about the the total affective and cognitive early phases of persistent back pain might improve from benign nature of their disease. Furthermore, number of reassurance was affective and cognitive parts of communication and they need valid information about the prognosis included patients supported. Subgroup differences with of their symptoms and adequate tools to deal is unknown. Kingdom presenting with prospective cohorts in reassurance in improvement in consultation exit outcomes. In poorly included verbal and enablement, reduced contrast, affective reassurance was associated at best only understood nonverbal health care utilization with improved satisfaction and at worst with poorer aetiology, and communication outcomes. In 3 high-methodology studies, an association for whom further showing caring, was found between affective reassurance and higher tests and empathy, and symptom burden and less improvement at follow-up. Advice as an back pain may be a valuable treatment adjunct to exercise: component for this patient subgroup. Advice as exercise, and/or functional activities to promote part of a functional active self-management. They Health care use and were based on uniform beliefs delivery of information, either with booklets or with standardized oral information provided by the care provider. Other studies compared training plus devices does not prevent back pain or back to manual devices. The intensity of or intensity of non lifting aids to no intervention (3) and to training only (1). Confidence intervals around the effect estimates were cohort studies) Treatment studies: still wide due to the adjustment for the design effect of Time to return-to clustered studies. The results of the cohort studies were work, proportion of similar to those of the randomized studies. Relaxation Massage 61 Furlan et 2010 Canada Adults (age 18 years) with Systematic Massage Pain Massage was superior to placebo or no treatment in Massage was superior to placebo or no al. Due to purposes) Functional status as findings for the effectiveness of massage therapy for the common methodological flaws in the primary Acute/subacute nonspecific measured by treatment of nonspecific low back pain when compared research, which informed the systematic low back pain (n=322) validated tools against other manual therapies (such as mobilization), reviews, recommendations arising from this Chronic nonspecific low Assessment of range standard medical care, and acupuncture evidence base should be interpreted with back pain (n=2, 117) of motion caution. Yoga 64 Cramer et 2013 Germany Patients with Systematic Yoga Pain There was strong evidence for short-term effects on pain this systematic review found strong evidence al. There was no evidence for either short-term or long-term effects on health-related quality of life. All papers had significant limitations results appear promising, but further well identified, however. The strongest and most consistent (n=743) heterogeneity in post-treatment effect sizes was low. Comparisons between groups showed significant differences between group scores at baseline 6) Oswestry Disability Index scores show baseline yoga at 24. Pre and post-pain reduction in control (Visual Analogue Scale) same as for yoga group, but sit and reach scores not significant for control group. There was low quality evidence that spinal manipulation reduces pain and functional disability more than ultrasound over the short to medium term. There is also very low quality evidence that there is no clear benefit on any outcome measure between electrical stimulation and therapeutic ultrasound. None of the included studies reported on adverse events related to the application of therapeutic ultrasound. In the absence of such only study comparing ultrasound versus a sham procedure evidence, the clinical use of these forms of are unreliable because of the inappropriateness of the sham treatment is not justified and should be procedure, low sample size, and lack of adjustment for discouraged. There mobility (extension, flexion), immediately after the was insufficient data to explore subgroup treatment for low back pain. The trial results were inconsistent due sham-acupuncture tended to produce negative results. Strong efforts are (pain medication, mobilization, laser therapy) were less warranted to improve the conduct methodology consistent. Two studies demonstrated treatment, but no conclusions can be drawn low back pain acupuncture points scores a significant difference between acupuncture treatment and about its effectiveness over other treatment for 12 weeks or along a meridian) no treatment or routine care at 8 weeks and 3 months. There was no evidence in support of acupuncture over transcutaneous electrical nerve stimulation. Compared with sham acupuncture, acupuncture Patient satisfaction may more effectively relieve pain (2 studies; mean Analgesic use difference, 9. Overall, findings on the effectiveness of acupuncture was superior to other active unknown. For chronic low-back pain, acupuncture is specific low low back pain, and functional status observed immediately after the end of the sessions and at more effective for pain relief and functional back pain and dry-needling for Physical examination short-term follow-up. There is evidence that acupuncture, improvement than no treatment or sham myofascial pain myofascial pain Return to work added to other conventional therapies, relieves pain and treatment immediately after treatment and in syndrome in syndrome in the low Complications improves function better than the conventional therapies the short-term only.

Disturbances of the reproductive system in male athletes are rarely discussed red carpet treatment generic reminyl 8 mg visa, but may also exist (90) medications rapid atrial fibrillation order reminyl 4mg without a prescription. Well-trained individuals have lowered insulin concentrations in plasma medicine 19th century cheap 8 mg reminyl overnight delivery, both basally and after sugar intake medicine wheel teachings generic reminyl 4 mg without prescription, due to both a reduced release of insulin from the islets of Langerhans (78) and an increased tissue sensitivity to insulin (79) symptoms 3 days dpo purchase reminyl 8mg mastercard. The increased insulin sensitivity is strongly linked to the reduced risk of having cardiovascular disease that is characteristic of physically trained individuals medicine you take at first sign of cold purchase genuine reminyl online. As described above in the section on adipose tissues symptoms 5th disease order reminyl 4mg overnight delivery, regular exercise leads to an increased capacity for lipol ysis in the adipose tissue medicinenetcom buy 8 mg reminyl visa. This contributes to a well-trained person being able to main tain a sufficient fat release during physical exertion even though the activation of the sympathetic nervous system, which controls lipolysis, is sharply reduced. Regular exercise has a carbohydrate-saving effect by a large part of the energy need being met with the burning of fat. In spite of this, regular physical exercise leads to a greater capacity for gluconeogenesis in the liver. The effect of endurance training on a few physiological reactions during sub-maximum and maximum exertion. Stromme, Professor emeritus, Norwegian School of Sport Sciences, Oslo, for constructive points of view and updates. Modulation of extracellular matrix genes reflects the magnitude of physiological adap tation to aerobic exercise training in humans. Human muscle gene expression responses to endurance exercise provide a novel per spective on Duchenne muscular dystrophy. Limiting factors for maximum oxygen uptake and determi nants of endurance performance. Moderate exercise, postprandial lipidemia, and skeletal muscle lipoprotein lipase activity. Body-composition assessment via air-displace ment plethysmography in adults and children. Importance and adaptations to exercise training, environmental stresses, and trauma/ sickness. Effects of submaximal exercise on high-density lipoproteinc holesterol subfractions. Site-specific skeletal response to long-term weight training seems to be attributable to principal loading modality. Effect of long-term impactloading on mass, size, and estimated strength of humerus and radius of female racquetsports players. A peripheral quantitative computed tomography study between young and old starters and controls. Functional strain in bone tissue as an objective, and controlling stimulus for adaptive bone remodelling. Self-reported lifetime physical activity and areal bone mineral density in healthy postmenopausal women. Distance of walking in childhood and femoral bone density in perimenopausal women. Functional analysis of articular cartilage deformation, recovery, and fluid flow following dynamic exercise in vivo. A meta-analysis of the factors affecting exercise-induced changes in body mass, fat mass and fat-free mass in males and females. The effect of exercise training on hormone-sensitive lipase in rat intra-abdominal adipose tissue and muscle. Straczkowski M, Kowalska I, Dzienis-Straczkowska S, Stepien A, Skibinska E, Szelachowska M, et al. Changes in tumor necrosis factor-alpha system and insulin sen sitivity during an exercise training program in obese women with normal and impaired glucose tolerance. Relationship between arterial and portal vein immunoreactive glucagon during exercise. Interactions between glucagon and other counterregulatory hormones during normoglycemic and hypoglycemic exercise in dogs. Adaptation of the hypothalamo pituitary adrenal axis to chronic exercise stress in humans. Ten days of exercise training reduces glucose production and utilization during moderate-intensity exercise. Habitual consumption of eggs does not alter the beneficial effects of endurance training on plasma lipids and lipoprotein metabolism in untrained men and women. Mechanisms for exercise training-induced increases in skeletal muscle blood flow capacity: differences with interval sprint training versus aerobic endurance training. This chapter describes recommendations on physical activity, both in general and in relation to aerobic fitness, strength and flexibility. The link between physical activity, health and physical capacity is also described, as well as the scientific background of the current recommenda tions in brief. To facilitate the prescription of physical activity, a strategy is also outlined for the application of the recommendations through the activity pyramid. A summary of the health-enhancing recommendations: All individuals should be physically active for a combined minimum of 30 minutes, prefe rably every day. Additional health effects can be achieved if the daily amount or intensity is increased beyond this. Activity pyramid To make it easier to prescribe physical activity, the activity pyramid can be an aid (see figure 1). The principle is that the activities further down in the pyramid are done more often and at a lower intensity than the activities higher up. Activities higher up in the pyramid also provide improvements in aerobic fitness, strength and flexibility. Physical activity has various dimen sions such as intensity, duration and frequency. Overall physical activity (a combination of the aforementioned factors) is related to various health variables in a so-called dose response relationship. This relationship between physical activity and health benefits (risk reduction) appears as a continuum, which does not appear to have any lower boundary. The various health parameters (such as those with regard to osteoporosis, mental illness, obesity and risk factors for cardiovascular disease) probably have different dose-response relationships, but this has not been sufficiently studied. The recommendations for physical activity and expected health effects are also reliant on the starting point, both with regard to activity level and risk profile. This means that the lower the activity level and the worse the risk profile is, the greater the effect can be expected to be if the activity level increases. It has accordingly been shown that the largest health difference is between people that are physically inactive and those that are a little physically active. This means that significant health benefits can be achieved through regular, moderate physical activity. Physically active individuals run half the risk of dying from cardiovascular disease as sedentary persons of the same age. Physical activity also decreases the risk of having high blood pressure, age-related diabetes and colon cancer. Quality of life is also improved by physical activity due to greater mental well-being and better physical health. There is also strong support for physically active individuals having a lower risk of being affected by brittle bones, bone fractures caused by falls, blood clots, obesity and mental disorders. In light of this, all clinically active physicians should advise their patients regarding physical activity adjusted to their state of health and personal lifestyle. The scientific support structure was further deepened in the report Physical activity and health. A report of the Surgeon General (2) and has recently been updated and clarified by the American College of Sports Medicine and the American Heart Association (3). The intensity should be at least moderate, which means that one is able to talk, but not to sing, i. This type of exercise is denoted as aerobic physical activity in these guidelines. Exercise of moderate intensity can be replaced by exercise of higher intensity (vigorous intensity). The same amount of energy is expended in these two examples, but in a shorter period of time in the alternative with higher intensity. Everyone is recommended to do strength training and flexibility exercises at least two times per week according to table 2. More health benefits are achieved if the amount of physical activity is increased from 150 to 300 minutes if the intensity is moderate and from 75 to 150 minutes if the inten sity is vigorous. The amount of physical activity can be expressed with the help of energy measurements, such as kilocalories (kcal) or kilojoules (kJ). These relationships are based on epidemiological studies, meaning studies at a population level that often include thousands of individuals. In the second version from 1990, strength and flexibility training were also included. The latest and third version from 1998 (16) regarding aerobic fitness, strength and flexibility is somewhat modified and compares the 2. In contrast to the health-enhancing recommendations, recommendations for aerobic fitness and strength are based on a dose-response relationship between the exercise inten sity, duration or frequency on one hand and measurements of aerobic fitness, such as maximal oxygen uptake or measurements of strength, on the other. These relationships are most often obtained through experimental studies on significantly fewer individuals than in the epidemiological studies. Note that the training of aerobic fitness and strength also leads to improved health in addition to providing specific effects in the form of improved physical capacity. This is because the intensity requirement is higher for the recommendations regarding physical capacity and consequently, the risks of negative effects also increase, particularly for individuals with chronic diseases. Intensity According to the health-enhancing recommendations, intensity can be either moderate or more intense to achieve positive health effects. Consequently, intensity is not directly decisive to the health effect, but rather the total energy expenditure seems to be more significant to the effect. However, at higher intensity, one should keep in mind that the body needs to recover for the optimal effect of the exercise, meaning that days of rest should be included. In terms of improving aerobic fitness and strength, a certain intensity must be achieved to obtain optimal effects, an intensity that is higher than moderate for the majority of individuals (16). Combined means that one can accumulate activity over the day, such as three bouts of 10 minutes each. This is based on the fact that the activities mapped out in the major epidemiological studies, on 46 physical activity in the prevention and treatment of disease which the recommendations are based, may have been carried out intermittently during the day. Examples of such activities include climbing stairs, walking to and from work, and household and gardening work. The minimum amount given as 30 minutes of daily physical activity corresponds to a daily energy expenditure of approximately 150 kcal per day or approximately 1, 000 kcal per week. From a practical perspective, it is easier to incorporate physical activity in daily activities if everyday activities in particular can be used. In addition, the risk for strain injuries increases if the frequency is too high in aerobic and strength exercise. This is on condition that the chosen intensity is not so high that the duration is extremely short and the energy expenditure is thereby below that which corresponds to a 30-minute brisk daily walk, or approximately 150 kcal per day. However, at higher intensity, the risks of cardiovascular complications increase (23). It should be noted that in regular exercise, the total risk across the day is reduced in terms of the risk of having a cardiovascular complication, although the risk during the actual exercise session is elevated (23). However, the increased risk in connec tion with a single exercise session appears to be lower for women than for men (24). Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease. The recommended quantity and quality of exer cise for developing and maintaining cardiorespiratory and muscular fitness and flex ibility in healthy adults. Leisure-time physical activity levels and risk of coronary heart disease and death. The association of changes in physical activity level and other lifestyle characteristics with mortality among men. Effects on adherence, cardiorespiratory fitness, and weight loss in overweight women. A scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity and Metabolism. A sedentary life style entails a sharply increased risk of disease and premature death (1, 2). Lifestyle related illness entails large costs and is consequently a major burden on healthcare services. Individuals of all ages, both men and women, achieve health benefits by exer cising, and greater physical activity is also important to improve well-being and quality of life (1, 3, 4). Increasing physical activity is therefore an important task for society in general and for healthcare in particular. Physical activity is now included as an important component in the treatment and prevention of various diseases. Here, a number of different experts in various areas have compiled the latest evidence of the connection between physical activity and health. This means all types of muscle activity such as walking, household and gardening work, and physical strain in work, outdoor life, exercise and training. It is important to emphasize that the main part of our weekly expenditure of energy in the form of movement can be associated with physical activity not tied to scheduled exercise and sports. This primarily concerns everyday physical activity, active transport, physical activity at work, physical activity during leisure time in the home or as a hobby, exercise, training and sports. The major health potential lies in increasing our overall level of phys ical activity, both in connection with work and during free time (5). From theory to practice Physical activity by prescription Interest in promoting physical activity has grown in healthcare. Both professional organi sations and healthcare personnel have a positive view of prescribing physical activity to patients (6, 7).

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